LETTERS TO THE JOURNAL 367 frontal tumour. The optic atrophy is commonly felt to Sir, result from optic nerve compression and the contralateral Apraclonidine in the Management of Glaucomatocy­ 1.2 papilloedema from increased intracranial pressure. clitic crisis Another mechanism suggests that Foster Kennedy syn­ Glaucomatocyclitic cnSlS (Posner-Schlossman syn­ drome is due to bilateral direct optic nerve compression by drome) is a unilateral inflammation of the uveal tract in a midline basal mass or less commonly by long-standing which signs of an acute increase in intraocular pressure increased intracranial pressure without direct com­ predominate. As the aetiology is doubtful, numerous treat­ pression of either nerve.3 ments have been suggested, the main aim being to reduce Since the early cases of Foster Kennedy syndrome, the exceptionally high intraocular pressure which, left many cases have been reported in the literature caused by untreated, will cause permanent optic nerve damage. other tumours, especially meningiomas such as olfactory Apraclonidine hydrochloride I %, a clonidine deriva­ groove and sphenoid ridge meningiomas, with gliomas tive and a peripheral alpha-adrenergic agonist. was devel­ occasionally reported.�-7 To our knowledge, nasopharyn­ oped to lower intraocular pressure while minimising geal carcinoma is rarely reported in the literature as a systemic side effects. It has specificrecept or-binding and cause of Foster Kennedy syndrome. physico chemical properties that limit its access to the cen­ Other terms have been used in the literature to describe tral nervous system. In normal human volunteers it pro­ atypical cases of Foster Kennedy syndrome. 'Pseudo Fos­ duces a significant fall in intraocular pressure. I ter Kennedy syndrome' has been used to describe cases Apraclonidine hydrochloride I % is being used to reduce caused by non-compressive pathology such as anterior the intraocular pressure elevation after anterior segment ischaemic optic neuropathy and optic neuritis.x 'Pseudo­ laser surgery. It is effective in eliminating the large, acute pseudo Foster Kennedy syndrome' has been used to elevation in intraocular pressure after argon laser trabecu­ describe a case caused by two different pathologies such loplasty.23 It can also be used as an adjunctive glaucoma as meningioma and ischaemic optic neuropathy causing therapy.� optic atrophy in one eye and swollen optic disc in the Case Report 1 other.Y The patient was a 37-year-old Malay woman referred by her general practitioner with a diagnosis of acute conges­ G. Zohdy tive glaucoma of the left eye. She complained of left-sided Eye Department, headache, and mild pain and redness of the left eye with Eye, Ear and Throat Hospital, slight blurring of vision for the preceding 3 days. On ques­ Murivance, tioning she said that she saw haloes from the day of onset. Shrewsbury SY I IJS, UK This was her firstep isode. Examination showed that her vision was 6/6 part, but M. Ghabra she said that she felt as though she was seeing through C. Donogue water. Slit lamp examination did not show any significant oedema of the cornea. There were six unpigmented pre­ Stonehouse Hospital, cipitates on the posterior surface of the cornea. There were Scotland, UK no obvious precipitates at the angle. Aqueous did not show significant flare or cells. Gonioscopy revealed that the chamber angle was wide open. The pupil reacted less References briskly compared with the fellow eye. The iris was similar in character when compared with the fellow eye. Posterior I. Kennedy F. Retrobulbar neuritis as an exact diagnostic sign of segment was normal. The intraocular pressure in the left certain tumours and abscesses in the frontal lobes. Am J Med Sci 191 1;142:355-68. eye was 50 mmHg and in the right eye was 14 mmHg. 2. Walsh FB. Clinical neuro-opthalmology. Vo l. 3. 3rd ed. Balti­ At 9.50 a.m. the patient was asked to lie down and 1 more: William & Wilkins, 1969, pp. 63. 2171. drop of apraclonidine I % was instilled in the conjunctival 3. Watnick RL, Trobe JD. Bilateral optic nerve compression as a sac. The pressure was monitored every hour until mechanism for the Foster Kennedy syndrome. Ophthalmology 1989;96: 1 783-97. 10.00 p.m. and again at 8.00 a.m. the next morning. 4. Jarus GD, Feldon SE. Clinical and computed tomographic find­ Within 1 hour the pressure dropped from 50 mmHg to ings in the Foster Kennedy syndrome. Am J Ophthalmol 18 mmHg. It remained at 18 mmHg for 6 hours and then 1982;93:31 7-22. rose to 22 mmHg during the seventh hour. Another drop 5. Jefferson G. The Doyne Lecture. On compression and invasion of apraclonidine was instilled. Within an hour the pressure of the optic nerves and chiasma by neighbouring gliomas. Trans Ophthalmol Soc UK 1945 ;65: 262-304. went down to 18 mmHg and in another hour to 14 mmHg, 6. Sachs E. Symptomatology of a group of frontal lobe lesions. and remained the same throughout 3 days of monitoring. Brain 1927;50:474-9. Examination on the third day showed the fields were 7. Wagener HP, Love JG. Fields of vision in cases of tumour of normal. There was no significant fluctuation of pressure Rathke's pouch. Arch Ophthalmol 1943:29:873-87. 8. Schatz NJ, Smith JL. Non-tumour causes of Fostcr Kcnnedy syn­ on regular follow-up. drome. J Neurosurg 1967;27:27--44. Case Report 2 9. Gelvwan MJ, Seidman M, Kupcrsmith M. Pseudo-pseudo-Foster Kennedy syndrome. J Clin Neuro-ophthalmol 1988;8:49-52. The patient was a 25-year-old Chinese woman. She was 368 LETTERS TO THE JOURNAL

seen during the sixth episode of glaucomatocyclitic crisis, Sir, which occurred, on average, once a year. She recognised Oestrogens and Macular Holes: a Postal Questionnaire the symptoms and signs without difficultyand came to my Macular holes are an important cause of central visual loss morning clinic. She had a left-sided mild headache, slight in the elderly population, and there is a strong female pre­ pain in the left eye with mild congestion, slight blurring of ponderance (70% ).1 Hormonal changes around the time of vision and haloes around bright light. In the past she was the menopause, previous hysterectomy, and hormone treated with Diamox 250 mg q.i.d. and dexamethasone replacement therapy (HRT) have been cited as possible eyedrops q.i.d. It took, on average, 3 days for the pressure risk factors"·3 though not studied in greater detail. Oestro­ to settle down to normal. gens have well-documented stimulatory effects on col­ Examination showed the collected vision was 6/6 in lagen and hyaluronic acid in the skin, and it is possible both eyes. Slit lamp examination did not show any signifi­ they may be similarly active within the eye. Factors such cant oedema of the cornea. There was no evidence of ker­ as the menopause, hysterectomy, or postmenopausal HRT atitic precipitates on the posterior surface of the cornea. could modify this effect. We therefore undertook a postal There were no obvious precipitates at the angle. Aqueous questionnaire of 103 female patients with macular holes, did not show significant flare or cells. Gonioscopy and asked for details of gynaecological and obstetric revealed that the chamber angle was wide open. The pupil history. Since 1988, patients with idiopathic full or partial reacted less briskly compared with the fellow eye. The iris thickness macular holes have been recruited for research was similar in character when compared with the fellow studies at Moorfields Eye Hospital. Those with 6 dioptres eye in spite of repeated attacks. or more of myopia, and those with a history of ocular At 9.10 a.m. the patient was asked to lie down and 1 trauma or surgery, have been excluded. From this database drop of apraclonidine 1 % was instilled in the conjunctival we were able to identify 103 fe male patients for the ques­ sac. The intraocular pressure, which was initially tionnaire, and they all received an introductory letter 54 mmHg, dropped to 38 mmHg in an hour, then to 24, explaining the purpose of our study, along with the ques­ 20, 17 and 14 mmHg over the following 4 hours. It stabil­ tionnaire itself. (The study was carried out between March ised at 14 mmHg and did not rise again over 3 days of and June of 1992.) Ninety questionnaires were returned monitoring. Examination on the third day showed the (response rate 87%). fields were normal. It was not possible to definethe age at onset of macular hole formation since for many patients the diagnosis had been made during the course of a routine eye test, and the Discussion time of onset was therefore unknown. Average age was 66 Two patients with typical glaucomatocyclitic crisis was years (range 46-85 years). treated with apraclonidine hydrochloride 1 %. Both The firstfour questions asked were as follows: showed a fall in intraocular pressure within an hour of How old were you when your periods started? application of the drops. In one patient the attack was How many times have you been pregnant? aborted with a single drop. In the other patient there was an increase in pressure after 6 hours which was returned to How many children have you given birth to? normal after one more application. No other medication Have you ever used a contraceptive pill? was used. Apraclonidine may prove to be useful in the Patients experienced the menarche at an average age of 13 treatment of glaucomatocyclitic crises. years (range 1 1-16 years), became pregnant 2.5 times, and gave live births on 2.3 occasions. Fourteen of the 90 P. Muthusamy, MBBS (Madras), DO (Lond), FRCOphth, patients (15%) had taken an oral contraceptive preparation FRCSEd at some time, for an average of 6.7 years. All these figures Muthu Eye Clinic and Surgery are similar to those for the general female population. 88300 Kota Kinabalu We then asked: Sabah Have you ever had hot flushes? Malaysia Have you passed the menopause? Have you had a hysterectomy, and if so were the ovaries References removed also? I. Sugar S, Sorsby A. Modern ophthalmology, ed. A. Sorsby. Vol 4. Sixty-three of 88 patients (7 1 %) had experienced hot London: Butterworth, 1972:644. flushes at some time in the perimenopausal period, and 2. Abrams DA. The safety and efficacyof topical I o/c, ALO 2145. (p-aminoclonidine hydrochloride) in normal volunteers. Arch their average age at onset was 47.6 years. Eighty-four of Ophthalmol 1987; 105: 1205-7. 89 patients (94%) were postmenopausal at the time of . 3. Brown RH. ALO 2145 reduces the intraocular pressure elevatIOn diagnosis of their macular hole, the average age at meno­ after anterior segment laser surgery. Ophthalmology 1988;95: pause being 50 years. Seventeen of 85 patients (20%) had 378-83. 4. Robin AL. Effectof ALO 2145 on intraocular pressure following undergone hysterectomy, and of the 12 patients within this argon laser trabeculoplasty. Arch Ophthalmol 1987: 105:646-50. group who answered the associated question on oophorec-